Healthcare Provider Details

I. General information

NPI: 1477984656
Provider Name (Legal Business Name): THOMAS DUST PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 HEALTH CENTER DR
MATTOON IL
61938-4693
US

IV. Provider business mailing address

PO BOX 372
MATTOON IL
61938-0372
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-2250
  • Fax: 217-258-2249
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-005945
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: